Basic Information
| Provider Information | |||||||||
| NPI: | 1356413017 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELOIT CARE LLC | ||||||||
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| OtherOrganizationName: | BELOIT HEALTH & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 W MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532032903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149088119 | ||||||||
| FaxNumber: | 4149087105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 W HART RD | ||||||||
| Address2: | |||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535112230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083652554 | ||||||||
| FaxNumber: | 6083650198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 06/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | THIEL | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 4149088119 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20198000 | 05 | WI | MEDICAID |